Topical Legal & Policy Research

Governmental Benefits

Center for Medicare and Medicaid Services

What: Formerly known as Health Care Financing Administration (HCFA), the Center for Medicare and Medicaid Services (CMS) administers the Medicare and Medicaid programs.  In addition, CMS has responsibility for implementation of various provisions of Health Insurance Portability and Accountability Act (HIPAA), the State Children's Health Insurance Program (SCHIP), and regulates clinical study programs involving humans through the Clinical Laboratory Improvement Amendments (CLIA).  For advocates, the site offers a wealth of legal and program information in addition to consumer education materials.
How to search:

Medicare

• Medicare Legal Research
  • Social Security Act - Links you to the Social Security Compilation of Laws Web site.  Browse Medicare specific titles by Table of Contents or topical Index.  (See above). 
  • Medicare Regulations - Users may search current or proposed regulations relating to or affecting Medicare.  The Web site organizes the regulations by quarter: Regulations Published this Quarter, Regulations Published Last Quarter, and Regulations Under Development this Quarter.  On each Web site, the user may browse a list of regulations affecting specific sections of the Medicare program for the respective quarter.  Easy access to Proposed Regulations Open for Comment and Meeting Notices may facillitate participation in the rulemaking process.
  • CMS Rulings - Rulings provide clarification and interpretation of complex or ambiguous provisions of the law or regulations.  TheWeb site permits browsing of decisions organized by date.
• Medicare Statutory and Regulatory Citations. Medicare statutory and regulatory citations are listed here by general topic. Social Security Act References, if available, are provided in italics. This list is not comprehensive. It is designed to present a broad overview of Medicare law and regulations. To find the statutes on the Internet, click here. To find the regulations on the Internet, click here.   
  • Medicare Eligibility and Enrollment
    • Eligibility and Enrollment: 42 U.S.C. § 1395c (Social Security Act, Sec. 1811); 42 U.S.C. §1395p (Social Security Act, Sec. 1837); 42 U.S.C. §1395i-2 (a) (Social Security Act, Sec. 1818)
    • Medicare Part A Eligibility and Enrollment: 42 C.F.R. Part 406                                
    • Medicare Part B Eligibility and Enrollment: 42 C.F.R. Part 407                                
    • Medicare Premiums and Enrollment Periods: 42 U.S.C. §1395i-2 (a) (Social Security Act, Sec. 1818)
    • Medicare Part A Premiums: 42 C.F.R. Part 406
    • Medicare Part B Premiums: 42 C.F.R. Part 408
    • Medicare + Choice: 42 U.S.C.§ 1395w-21 (Social Security Act, Sec. 1851-1859); 42 C.F.R. Part 422; 42 C.F.R Part 417 (HMO, Competitive plans)
    • Medicare as Secondary & Employer Group Health Plans: 42 CFR §§411.170 - .206
  • Medicare Appeals: 42 U.S.C § 1395ff (Social Security Act, Sec. 1869 1869A)
    • Traditional Medicare Appeals: 42 U.S.C §1395w-22 (Social Security Act, Sec. 1852)
    • Applicability of Social Security Appeal Guidelines to Medicare: 20 C.F.R. §§404.900-999d
    • Medicare Part A Appeals: 42 C.F.R §§405.701 - .750
    • Medicare Part B Appeals: 42 C.F.R §§405.801 - .857
    • National Coverage Determinations: 42 C.F.R §§405.860 - .877
  • Medicare Part A
    • Medicare Part A hospital benefit:
      • Definitions: 42 U.S.C.§1395x(b) (Social Security Act, Sec. 1861);
      • Scope of Benefits: 42 U.S.C. § 1395d(a) (Social Security Act, Sec. 1812);
      • Hospital Coverage Rules: General: 42 C.F.R §§ 409.1-.26;
      • Hospital benefit periods ("spell of illness"): 42 C.F.R. §§409.60-.68;
      • Hospital co-insurance: 42 C.F.R. §§409.80-.83;
      • Psychiatric Hospitalization Rules: 42 C.F.R. §§409.62-.63;
      • Lifetime Reserve Days: 42 C.F.R. §§409.65-.66;
      • Prospective Payment System for Acute Care Hospitals (AKA "DRGs"): 42 U.S.C. § 1395ww(d) (Social Security Act, Sec. 1886);
      • Beneficiary Liability for Custodial Care: 42 C.F.R. §§411.404;
      • Patient Certification for Hospitalization: 42 C.F.R. §§424.10-.27
  • Medicare Skilled Nursing Facility (SNF) benefit
    • Definitions: 42 U.S.C. § 1395x(h)-(i); (Social Security Act, Sec. 1861);
    • Benefit Period and Scope of Coverage: 42 U.S.C. § 1395d(a)(2)(A); (Social Security Act, Sec. 1812);
    • Coverage Criteria: 42 U.S.C. § 1395f(a)(2)(B); (Social Security Act, Sec. 1814);
    • Skilled Care Criteria:  42 C.F.R. §§409.31-.33;
    • SNF Coverage Rules: 42 C.F.R. § 409.31-.36;
    • "Daily Care" Requirement: 42 C.F.R. §§409.34;
    • "Practical Matter" Requirement: 42 C.F.R. §§409.35;
    • SNF Co-payments: 42 C.F.R. §§409.85  
  • Medicare Home Health benefit
    • Definitions: 42 U.S.C. § 1395x(m); (Social Security Act, Sec. 1861); 1861 Def cont'd 42 U.S.C. § 1395x(f)(a); (Social Security Act, Sec. 1861);
    • Physician Certification Requirements: 42 U.S.C. § 1395n(a)(2); (Social Security Act, Sec. 1835);
    • Coverage Criteria: 42 U.S.C. § 1395f(a)(2); (Social Security Act, Sec. 1814); 42 C.F.R § 409.40- .50;
    • Beneficiary Requirements: 42 C.F.R § 409.42;
    • Plan of Care Requirement: 42 C.F.R § 409.43;
    • Skilled Requirements: 42 C.F.R § 409.44;
    • Home Health Aide Requirements: 42 C.F.R § 409.45(b);
    • Medicare Hospice benefit: 42 U.S.C. § 1395x(dd); (Social Security Act, Sec. 1861); 42 C.F.R Part 418
  • Medicare End-Stage Renal Disease (ESRD) Services: 42 C.F.R. §§ 405.2101 - .2112
  • Medicare Part B
    • Medicare Part B benefits
      • Scope of Covered Services: 42 U.S.C. § 1395k(a); (Social Security Act, Sec. 1832);
      • Definitions of Covered Services: 42 U.S.C. § 1395x; (Social Security Act, Sec. 1861); 42 C.F.R. Part 410;
      • Medicare Part B Fee Schedule: 42 U.S.C. § 1395w-4(g) (Social Security Act, Sec. 1848); 42 C.F.R. § 411.408;
      • Limits on Charges for Dually-Eligible Beneficiaries: 42 U.S.C. § 1395w-4(g)(3);
      • Mandatory Physician Submission of Medicare Claims: 42 U.S.C. § 1395w-4(g)(4)
  • Exclusions from Medicare Coverage
    • Services Not Reasonable and Necessary: 42 U.S.C. § 1395y(a)(1)(A) (Social Security Act, Sec. 1862);
    • Medicare as Secondary payer: 42 U.S.C. § 1395y (Social Security Act, Sec. 1862); 42 C.F.R. Part 411;
    • Secondary to Group Health Plans: Social Security Act, Sec. 1862(b)(1);
    • Secondary to Liability Insurance: Social Security Act, Sec. 1862(b)(2)(A);
    • Coordination of Medicare with other Health Benefits: Social Security Act, Sec. 1862(b)(4);
    • Various Exclusions, including: routine check-ups, most eyeglasses, hearing aides, personal comfort items, etc.: Social Security Act, Sec. 1862(a)(2)-(21);
  • Coverage Determinations and Local Medical Review Policy: 42 U.S.C § 1395ff(f) (Social Security Act, Sec. 1869A)
  • MediGap: 42 U.S.C. 1395ss (Social Security Act, Sec. 1882)
  • Electronic Claims Submission: Social Security Act, Sec. 1862(a)(22)
• Medicare Programs and Services
  • Medicare Manuals - Contain CMS policies and procedures as well as day-to-day operating instructions for Medicare contractors and others.
  • Medicare Coverage Database - Search function at bottom of page permits searches of National Coverage Determinations, National Coverage Analyses, and Laboratory National Coverage Determination databases.  These determinations set forth whether Medicare will cover, or not cover, specific services, procedures, or technologies on a national basis. The Medicare Coverage Manual and the Local Medical Review Policy (LMRP) manual sections permits access to the policies that govern the LMRPs decision-making process.
  • Medicare Consumer site - Takes users from the CMS Web site to the Medicare.gov Web site.  This Web site offers consumer ready information regarding Medicare Enrollment, Medicare Billing, Long-term Care, Plan Choices, and Medicaid Enrollment.  The Personal Plan Finder, which asks a series of questions of consumers to help them determine their Medicare plan options. 

More resources on Legal and Policy Research on Governmental Benefits from CMS.